Free Flap Reconstruction in 1999 and 2009: Changing Case Characteristics and Outcomes
ABSTRACT To compare free flap reconstructive cases from 1999 and 2009 with respect to patient characteristics, surgical characteristics, outcomes, and complications; and to discuss the evolution in free flap reconstruction at a single institution during this time period.
Retrospective cohort comparison.
Free flap reconstruction cases from 1999 and 2009 were collected into two cohorts. Retrospective chart review was performed to extract patient characteristics, surgical characteristics, and outcomes. Cohorts were compared with respect to extracted data with statistical significance set at P < .05.
There were 39 free flap reconstructions performed in 1999 and 81 performed in 2009. Patients in the 2009 cohort had higher American Society of Anesthesiologists scores and incidence of cardiovascular disease (P = .009 and .0045, respectively). Median operative time decreased from 12 hours in 1999 to 9 hours in 2009 (P < .0001). Median length of stay decreased from 14 to 9 days (P = .0006). The rate of perioperative return to the operating room to manage complications decreased from 30% to 17% (P = .103). There were five unsalvaged flap failures in 1999 (12.8%) compared to two failures in 2009 (2.5%) (P = .036).
Patients undergoing free flap reconstruction are increasingly older and have more medical comorbidities. Despite these challenges, increased efficiency and teamwork stemming from accumulated institutional experience have led to decreased operative times, length of stay, and complication rates and increased overall success rates.
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ABSTRACT: Cutaneous defects of the neck require a different algorithm for reconstruction as compared to facial defects. Depending on the location and size of the defect, a variety of reconstructive techniques can be used, from secondary healing to pedicled or free flaps. Additionally, patient co-morbidities can negatively affect the outcomes of certain reconstructive options. We will describe a variety of techniques that are available to the head and neck or facial plastic surgeon for reconstruction of neck defects.Operative Techniques in Otolaryngology-Head and Neck Surgery 03/2013; 24(1):45–54. DOI:10.1016/j.otot.2013.01.001
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ABSTRACT: Objective To assess the advantages of using mechanical anastomotic systems in head and neck free tissue transfer.Study designCase series with chart review.SettingA university-based tertiary care center.Subjects and MethodsA retrospective review of mechanical venous coupler devices in head and neck reconstruction performed between October 2004 and December 2006. A total of 261 venous anastomoses were performed in 234 consecutive patients. Five types of flaps were performed: radial forearm (66%), anterior lateral thigh (12%), fibula (9%), rectus abdominis (8%), and latissimus dorsi (2%). Demographic data were collected, and the outcomes measured were flap survival and microvascular complications.ResultsThe size of the venous anastomosis ranged from 1.5 to 4.0 mm, with most being 3.0 mm (56%) followed by 3.5 mm (23%). The most common recipient vein used was a stump off the internal jugular vein (76%) followed by the external jugular vein (17%). Microvascular complications occurred in <5% (n = 11) of patients, with >50% of those being arterial insufficiency (n = 7). Total failures occurred in 3% (n = 7) of patients: 1.5% (n = 4) acute failures (<5 days) and 1.5% (n = 3) late failures. Of the acute failures, causes included venous congestion (n = 1) and arterial insufficiencies (n = 3). The venous coupler used in the failures was 3.0 mm in diameter. Free flap failures resulting from arterial insufficiency involved coupling to the external jugular vein, while the remaining free flap failures (n = 4) used the internal jugular vein.Conclusion With an early venous failure rate of 0.38%, mechanical anastomosis is an adequate alternative to hand-sewn techniques.Otolaryngology Head and Neck Surgery 04/2013; 149(1). DOI:10.1177/0194599813486875 · 1.72 Impact Factor
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ABSTRACT: Microsurgical free tissue transfer has become an increasingly valuable technique in reconstructive surgery. However, there is a paucity of evidence-based guidelines to direct management. A systematic review was performed to define strategies to optimize perioperative management. A systematic review of the literature was performed using key search terms. Strategies to guide patient management were identified, classified according to level of evidence, and used to devise recommendations in seven categories: patient temperature, anesthesia, fluid administration/blood transfusion, vasodilators, vasopressors, and anticoagulation. A total of 106 articles were selected and reviewed. High-level evidence was identified to guide practices in several key areas, including patient temperature, fluid management, vasopressor use, anticoagulation, and analgesic use. Current practices remain exceedingly diverse. Key strategies to improve patient outcomes can be defined from the available literature. Key evidence-based guidelines included that normothermia should be maintained perioperatively to improve outcomes (level of evidence 2b), and volume replacement should be maintained between 3.5 and 6.0 ml/kg per hour (level of evidence 2b). Vasopressors do not harm outcomes and may improve flap flow (level of evidence 1b), with most evidence supporting the use of norepinephrine over other vasopressors (level of evidence 1b). Dextran should be avoided (level of evidence 1b), and pump systems for local anesthetic infusion are beneficial following free flap breast reconstruction (level of evidence 1b). Further prospective studies will improve the quality of available evidence.Plastic & Reconstructive Surgery 04/2015; 135(1):290-9. DOI:10.1097/PRS.0000000000000839 · 3.33 Impact Factor